A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?
Notify the client's family to come visit client
Instruct the client return to their room
Ask the unlicensed assistive personnel (UAP) to push fluids
Assess the client's lung fields and temperature
The Correct Answer is D
A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.
B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.
C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.
D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clamping the chest tube near the water seal is not recommended because it can lead to complications such as a tension pneumothorax. The chest tube should remain unclamped unless instructed by the healthcare provider.
B. Repositioning the client may be necessary if the rise in the water seal chamber is due to a physical obstruction or positioning issue. However, this is not the first action to take.
C. A rise in the water seal chamber with inspiration (tidal fluctuation) is a normal finding in a chest tube system. It indicates that the lung is re-expanding and that the pleural space is still connected to the atmosphere. The nurse should continue to monitor the client and the chest tube system for any other changes.
D. Immediate notification of the provider is not necessary unless there are other signs of complications, such as sudden changes in the drainage amount, a lack of fluctuation, or signs of respiratory distress.
Correct Answer is C
Explanation
A. Assessing the patient’s vital signs is important but is not the first priority during an acute asthma attack. The primary concern is airway patency and breathing effectiveness.
B. Checking the patient’s blood pressure is part of a comprehensive assessment but is not the immediate priority in this scenario. It does not directly address the respiratory distress associated with an asthma attack.
C. Assessing the patient’s lung sounds is the first priority as it provides critical information about the severity of the airway obstruction and the effectiveness of the patient’s breathing. Identifying wheezing, diminished breath sounds, or silent chest (absence of airflow) is essential for immediate intervention.
D. Obtaining a complete medical history is important for long-term management but is not the priority during an acute asthma attack. Immediate assessment and stabilization take precedence.
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